BRIGHT FUTURES EXAM: EARLY ADOLESCENT (ages 11-14 )
NAME: / VISIT DATE: ______/______/______ / DOB: ___/____/____Actual Age:MaineCare I.D. #: / NO SHOW / Service Location Name and ID #:
Examiner’s Name: Examiner’s NPI #: Pay To NPI #:
MARK UNDER APPROPRIATE ANSWER , KEY: Mark Nl for normal, Ab for abnormal, or Y for yes, N for No
(1) CHILD HISTORY / (2) PHYSICAL EXAM / (3) IMMUNIZATIONS GIVEN
1. General health: / Nl / Ab / 36. Up to date? / Y / N
2. Illness Free / Y / N / 15. WT______lbs / Nl / Ab
3. Injury Free / Y / N / 16. HT______in / 37. HPV / Y / N
4. Allergies / Y / N / 17. BMI : % / Nl / Ab / 38. HPV / Y / N
18. Skin (acne) / Nl / Ab / 39. Tdap / Y / N
5. Meds / Y / N / 40. MCV #4 / Y / N
6. Exercise / Y / N / 19. Ear / Nl / Ab
7. Sports / Y / N
8. Diet / Nl / Ab / 20. Nose / Document vaccine brand below and record in Immpact2
9. Adequate calcium intake / Y / N / 21. Throat
10. Menses: / Y / N / 22. Teeth (caries, injury) / Nl / Ab
11. Family Hx of sudden death / Y / N / 23. Neck / Nl / Ab
Family Hx of depression / Y / N / 24. Lungs / Nl / Ab
Other: / Y / N / 25. Heart / Nl / Ab
12. Parent/Adolescent Interaction / Nl / Ab / (6) KEY ANTICIPATORY GUIDANCE
13. Does parent allow adolescent to be interviewed alone? / Y / N / 26. Abdomen / Nl / Ab / / * = key items
27. Genitalia / Nl / Ab
14. Dental appt in last year / Y / N / 28. Tanner stage: / Nl / Ab / *71. Use seat belt all the time
29. Pelvic exam if sexually active / Nl / Ab / 72. Use bike/ski/skate helmet
30. Testicle (discuss self-exam) / Y / N / 73. test smoke/carbon monoxide detectors
31. Breast (discuss self-ecam) / Y / N / 74. Keep home/care smoke-free
32. Musculoskeletal / Nl / Ab / 75. Sun exposure/sunscreen
33. Neuro / Nl / Ab / *76. Discuss proper athletic training
34. Extremities / Nl / Ab / *77. Confide in someone whenstressed, etc.
35. General hygiene / Nl / Ab / 78. Teach healthy choices for snacks/meals
(5) DEVELOPMENTAL /SCHOOL PERFORMANCE [ if discussed ] / *79. Include iron in diet (ie. meat, greens)
/ Social/Emotional Development: / / Physical dev. & Health Hazards: / *80. Manage weight through proper diet & exercise
49. Best friend / 59. Feelings about you appearance? ______/ *81. Brush teeth with little or no toothpaste 2x
50. Activities for fun:______/ 60. Average time watching TV, etc./ wk______/ *82. Sex education; safety, abstinence, ability to say ‘no’
51. Things good at:______/ 61. Smoke / 83. Avoid tobacco, alcohol, other substances
52. What worries you or makes you angry______/ 62. Chew tobacco, cigars / 84. Gun/weapon safety
53. Feel sad or alone? / 63. Drink alcohol / *85. Spend quality time with family
64. Take drugs / *86. Practice peer refusal skills
Family: / 65. Feel peer pressure? How do you handle this?
______ / 87. Participate in social & community activities
54. Who do you live with? ______/ 66. Started dating? / 88. Dental Appt
55. How is family relationship?
______/ 67. Wet dreams/ Started perio/Regular? / 89. 5-2-1-0, Avoid Juice/Soda/Candy
56. Do they listen to you? ______/ 68. Any questions about sex?
57. How are you doing in school?
______/ 69.Having sex with men/women/ both
/ 58. How often are you absent?
______/ 70. Use of birth control/condoms
(4) SCREENINGS if at risk or not done elsewhere
44. Annual Hct, Hgb / Y / N / 48. If sexually active discuss birth control, pregnancy, and STD risk.
41. Vision R20/____L20/____ / Nl / Ab / (if heavy menses, extreme wt. loss, etc.) / Nl / Ab
42. Hearing R__L__ / Nl / Ab / 45. High risk hyperlipidemia / Nl / Ab
43. PPD / Nl / Ab / 46. Teeth / Nl / Ab
If done , result: / Neg / Pos / 47. Lipid Results: ______/ Neg / Pos
MaineCare Member Services follow-up needed: [circle as appropriate]arrange transportation/find dentist/ find other provider/make appointment/ Public Health Nurse visit/ other